Between conventional and complementary medicine
Half of Canadians who use complementary and alternative medicines (CAMs) don't tell their doctors they do. Integrated care is opening the lines of communication.
Although millions of Canadians use complementary and alternative medicines (CAMs), as many as half don’t tell their doctors they do. For patients to tell their medical doctors, and for doctors to ask, we need new models of communication, care, and research. The good news is those changes have already begun.
Because patients benefit
“It’s my dream to see communication between alternative and conventional medicine,” says Sulay Stockner of Vancouver. “I’ve seen the changes in my three children from homeopathy and naturopathy. Why not combine knowledge?”
Charles Reif benefited from combined knowledge when he was diagnosed with prostate cancer. A retired architect who lives in the Gulf Islands off the coast of BC, Reif attended a cancer care centre called InspireHealth in Vancouver.
“My oncologist was very good at what he knew about,” Reif says. “But had I not taken on the diet and exercise changes I learned about at InspireHealth, talked to a doctor there at length, and used their library, there wouldn’t have been anything I was doing for myself about the cancer. My general health and preparedness for [prostate] surgery would have suffered as a result.”
Integrated care: a bridge over the divide
Dr. Teresa Clarke is a medical doctor and acupuncture practitioner on staff at InspireHealth in Vancouver. “It doesn’t matter what the diagnosis is,” Clarke says. “An integrated approach helps all diseases.”
“Integrated medicine” is the term used to describe the combination of treatments from conventional medicine and CAM for which there is reliable evidence of safety and effectiveness.
At InspireHealth Clarke meets with cancer patients for initial 90-minute consultations and follow-up appointments. She also runs a weekly acupuncture program for patients suffering from the side effects of chemotherapy.
“In consultations with patients,” Clarke says, “we look at medical treatment, CAM options, physical and psychological stresses, spiritual issues. We don’t push any option, but empower patients to make their own choices.”
InspireHealth charges an annual membership fee, but bursaries are available. New centres are opening in Kelowna, Prince George, Victoria, and Abbotsford, BC, in 2012.
Although oncologists refer patients to InspireHealth, they don’t work onsite. This aspect remains a “parallel” health care characteristic within the integrated InspireHealth model.
In the belly of the beast: a model for full integration
According to Lynda Balneaves, PhD, up to 80 percent of Canadian cancer patients use complementary medicine, but they’re frustrated that they can’t get the information and support they need about CAM within conventional cancer care.
“Patients say they want integrated, complete cancer care,” says Balneaves, a professor of nursing and the lead researcher at the Complementary Medicine Education and Outcomes (CAMEO) program in the BC Cancer Agency.
The program studies the CAM needs of cancer patients and brings the latest research to them through education sessions, support groups, and one-to-one coaching.
“We also want to help health care providers address questions at the bedside and not shut down when patients tell them about CAMs,” says Balneaves. “Patients have all these questions from their Internet searches. There’s lots of confusion.
“There are instances where a patient is taking a natural health product that’s clearing the effects of their chemo too fast,” she continues. “It’s not an intentional harm, just a lack of communication.”
To support patients to make safe decisions, CAMEO offers an online course for all health care practitioners working with oncology patients.
“We’re getting more evidence that some CAM therapies are helpful to cancer patients,” says Balneaves. “I think it’s our duty to inform patients. Respect for patient autonomy demands it.”
Parallel and connected
Parallel, independent health services often have their own approach to crossing the great divide between complementary and conventional care.
Lamia Gibson, co-owner of Six Degrees Community Acupuncture in Toronto, sees clients from the ages of 11 to 82 for ailments from low back pain and headaches to fertility issues and psoriasis.
“We encourage our clients to tell their medical doctors that they are receiving acupuncture treatment,” Gibson says, “especially for someone dealing with an illness.
“We want doctors to know the effectiveness of acupuncture. The evidence is there when people’s health improves and the only explanation is the acupuncture treatment.”
Communication has made an impact. In the last five years Gibson’s seen a change in how doctors are responding. “Some still scoff, but others are quite encouraging.”
Six Degrees operates from a community model of care. To lower costs, trained acupuncturists treat clients in a group setting. “A practitioner can treat four to six people in an hour, charge less, but still make money,” Gibson says. “It’s a creative solution to the cost of complementary care.”
Community practitioners use a “distal point” approach, inserting acupuncture needles into the head, hands, legs, face, and arms to activate and balance qi, so private treatment rooms aren’t necessary.
Group care may enhance healing and well-being, as Moira Simpson, a documentary film maker, found out.
As a cinematographer Simpson carries a camera for up to 12 hours a day and has developed chronic pain in her shoulders. But for her, cost is a critical issue. “I’m working in the arts during a recession,” she says. “There’s no way I could possibly afford to go to a massage therapist or a physio.”
At Poke, the community acupuncture clinic Simpson attended for pain treatment, she found a welcome atmosphere.
“It was really relaxing and calming,” she says. “Once, I fell asleep and had this amazing dream of a world where thousands of people were all coming to this waterfall. It was so peaceful. At home, I slept better after treatments.”
Chris McDowell, a media production technician and trainer, also found the therapy at Poke effective. “I went because my knee was really painful and the chiropractor who was helping me with it went on maternity leave.”
When asked if she’d tell her medical doctor about Poke, McDowell replies, “My doctor’s probably too busy for me to share information with. Now that I think of it, though, I will mention it to him.”
Community acupuncture clinics can also be found in Winnipeg, Kingston, and Victoria. To find one near you, go to pocacoop.com.
Sometimes it’s simple
“Sometimes it’s so simple,” says Sulay Stockner in Vancouver. “My daughter had a fungus in her nail and my doctor couldn’t give her medicine for it because she’s too young and the drug could cause side effects. But my naturopath said to use vinegar, so we did. And the fungus is gone.”
“My medical doctor, who is a very good doctor, would never ask me what I’ve learned from my naturopath or homeopath, although I do tell him,” Stockner says. “And he’d never refer me to a CAM therapist.”
Stockner acknowledges the time pressure medical doctors face. As well, doctors may face a legal quandary: in the US doctors have faced legal action when they referred a patient to an unregulated CAM practitioner and the patient was harmed.
Yet reputable CAM practitioners can offer help when conventional medicine can’t.
“The beauty of complementary medicine is it gives people hope even when their medical doctors can’t help them,” says classical homeopath Nicole Duelli. “Not as a cure for cancer or to prevent cancer, but to strengthen underlying resilience to everyday illnesses, to build up the immune system.”
One of Duelli’s specialties is the treatment of children, including those with recurring colds or earaches. “A child may have taken antibiotic after antibiotic, which deals with the infection in the moment, but the inner resilience isn’t there,” Duelli says.
“As an integrative medicine, homeopathy is great because it doesn’t interact with conventional medication, so if you need to take a drug, there’s no conflict.”
If you would like to tell your doctor about your CAM use or ask them for information, see the sidebar, “Tips for Talking to Your Doctor about CAM.”
Sometimes it’s complicated
“Some of the people who come to me have vague but uncomfortable symptoms, like fatigue or gastric distress, that the medical system can’t pinpoint,” says Diane Kent, a medical herbalist in Toronto. “Or they’ve had bad reactions to drugs or don’t respond the way they’re expected to, or find the side effects unbearable and want an alternative.”
Kent believes patients should tell their doctors about using CAMs, but doubts many of her clients will because they fear lack of interest or being told to stop. “To me my clients are saying, ‘I trust you to keep an eye on any interactions with these herbs, but I won’t tell my doctor.’”
Kent’s clients also seek the unique consultative approach of herbalists, one they can’t find in a doctor’s office.
“Typically I spend an hour and a half to two hours initially to go through the person’s past medical history, diet, and lifestyle,” Kent says. “I run through every body system to see if there are other symptoms the person’s not talking about.”
Some critics of herbal remedies have called for standardized clinical studies to ensure safety and effectiveness.
“Certainly where therapies are new I can see a good role for studies on vitamins, natural supplements, hormones,” Kent says. “But if something’s been around a long time, like herbs, we already have a lot of evidence about effectiveness and side effects because they’ve been tested on populations [using] for thousands of years.”
Studies on herbs, according to Kent, often lack validity because they’re based on a pharmaceutical model that looks for a herb to treat a symptom. “That’s not how we use herbs,” she says. “Herbalists custom-formulate a remedy based on everything we’ve learned from a specific individual.”
Kent pays close attention to studies on interactions between drugs and herbs, however, especially when the client is undergoing chemotherapy. St. John’s wort, for example, can reduce the effectiveness of some anticancer drugs.
“This is an area where there should be more communication between doctors and herbalists,” Kent says.
New research models, new benefits
In a health care system that’s already overloaded and underfunded, how much communication and integration is really possible?
Research may hold the key, says Lynda Balneaves of the CAMEO program.
“We need to look at CAMs from a cost-effectiveness perspective,” she says. “If acupuncture treatments result in a reduction in patients’ visits to doctors, reduced use of pharmaceutical drugs, a quicker return to work, an economic rationale needs to be added to [cost] the health care system.”
She also points out wasteful practices in CAM research. “In traditional Chinese medicine, for example, it’s individualized care, not standardized,” she says. “So you can’t do a standardized protocol in a research study. We need to create research designs that capture that totality.
“We know CAMs are being used in real-world situations and we need to study them that way, too,” she adds. “Otherwise we’re wasting money.”
Balneaves is a colleague of Marja Verhoef, PhD, the Canada Research Chair in Complementary Medicine at the University of Calgary. Verhoef is a pioneer in the development of a new model called whole systems research.
Whole systems research regards the relationship between a patient and a complementary practitioner as part of the therapy’s value that should be included in research.
“We know that relationship makes a difference and we need to account for it,” says Verhoef. The mind-body-spirit vision of CAM is part of its value, too. “In studies of cancer patients in particular,” Verhoef says, “they tell us the individualist, holistic approach of CAM medicine benefits them in ways beyond what conventional medicine has to offer.”
Verhoef is invited to lecture on CAMs and CAM research at some university medical schools, but so far there are no courses on CAMs included in degree programs. (See the sidebar on page 25 for information about how to find the latest reliable research on CAMs.)
Verhoef, who has been involved in studying CAM for 50 years, offers an encouraging end note: “I do think conventional practitioners are getting better at talking about it.”
We’re not there … yet
Although new models of care and research, and guidelines for more open communication exist, there’s no solution yet to the limited time medical doctors have to talk to and listen to their patients. And while there are increasing numbers of studies on the efficacy of some CAM therapies, there’s still limited recognition within the medical profession.
But with millions of Canadians already using CAMs, the only way to go is forward—into conversation and needed change.
Reliable resources: the latest CAM research
Tips for talking to your doctor about CAM